We report a case of a dystonic reaction possibly triggered by
propofol, which was managed successfully by turning the patient prone.

A 34-year-old woman presented for cervical dilatation and suction
curettage following a miscarriage during the first trimester of
pregnancy. She gave a history of having the "shakes" for about
30 minutes after her last anaesthetic for the same procedure. The rest
of her history and examination was unremarkable.

The "shakes" following her previous anaesthetic were
assumed to be related to the volatile anaesthetic agent or as a result
of being cold. Given the reaction was self-limiting, we were not unduly
concerned.

After an uneventful general anaesthetic, during which propofol,
fentanyl, sevoflurane and syntocinon were administered, the patient had
dystonic movements while in the recovery room, shortly after expelling
the laryngeal mask. The movements were of a writhing rhythmic nature and
involved her head, neck, arms and legs. The patient articulated that the
movements were just like her previous experience. Intravenous midazolam
2 mg stopped the movements for approximately five minutes but the
movements returned as the patient's conscious state improved.

We were planning to administer benztropine when a second
anaesthetist suggested nursing the patient prone and to the delight of
patient and staff, this stopped the movements. The patient remained
prone for 30 minutes and after turning supine had no further dystonic
movements.

A Medline[R] review was unable to find any cases where changing
position successfully terminated a dystonic reaction. The idea to nurse
this patient prone came from previous suggestions by Professor Colin
Goodchild (Monash University) who had witnessed its effectiveness in the
rat model of dystonia. Although uncertain, the effectiveness of this
manoeuvre is thought to relate to the change in proprioceptive input to
the spinal cord when spinal reflexes may be hyperexcitable due to a
propofol-induced glycinergic inhibition (C.Goodchild, personal
communication).

However, abnormal dystonic movements have also been attributed to a
propofol-induced imbalance of basal ganglia neurotransmitters, resulting
in an increase in excitatory cholinergic output (1). Therefore another
possible explanation for the effectiveness of turning prone is the
change in proprioceptive input to the basal ganglia. Of course the
cessation of her symptoms may have been a coincidental natural
resolution.

Regardless of the possible mechanism of action of this novel
treatment, we report this case to alert others to the possible use of an
easy and effective measure for managing dystonia and to encourage
further research and reporting in this area.